Okaloosa County BOCC — March 18, 2014 — Settlement Agreement — reading text

STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS Steven St. Clergy, Employee/Claimant, VS. OJCC#: 98-020187NSW Date of Accident: 8/20/98 Okaloosa County Board of Commissioners, Employer, and Johns Eastern, Carrier/Servicing Agent. / TLEM ENT P TTO 44.0.2 & fe TATU 001 The above-named parties hereby set forth the following agreement made for the specific purpose of discharging the employer/carrier/servicing agent from any further liability as to any and all dates of accident or injury, including, but not limited to the date(s) of accident listed above, for all past and future benefits under the Florida Workers’ Compensation Law, in exchange for the payment of a lump-sum of money to the claimant. The parties, therefore, stipulate as follows: 1. JURISDICTION - The Florida Department of Labor and Employment Security and the Judge of Compensation Claims (hereinafter referred to as "judge") appointed under F.S. §440.45 have jurisdiction of the subject and the parties hereto. 2. ION_OF ED}_AC - On 8/20/98, the employee (hereinafter designated as the claimant), contends he was injured by accident as contemplated under FS. §440.02(1} arising out of and in the course of employment with the employer in Okaloosa County, Florida, when, while lifting a body into the van, the body fell and claimant injured his back. 3. A KLY WAG MPEN - At the time of the injury, the claimant's average weekly wage was $815.12, thus making the compensation rate $494.00 per week. 4, PTION BENE D LON: RY OF DI DE I TAGN PERFORM TURE OF ANY IGNIF- PRE- NDITIONS F_ DESC Y(IE PERFORMED, IF ANY - Following the injury, claimant was treated by Dr. Dale Johns, and following GED was Ey by Dr. Johns on 1/8/01. By 10/4/00, Dr. Johns concluded that claimant could return to his previous job in the medical examiner's office, although the job was not then available. By May of 2001, claimant commenced employment with the Broward County Medical Examiner's Office as Medical Legal Investigator. He left that position in February of 2005 and became employed by the Volusia County Medical Examiner’s Office as Forensic Investigator. He resigned in October of 2008, and commenced customer service work in March of 2009 for a period of three months. After moving from the Northwest Florida location, claimant came under the care of Dr. Jarolem who put claimant at JS QED and Dr. Villalobos who put claimant at SD with an GD Dr. Allende perforned Ey on 8/9/11, and placed claimant i. Dr. Allende limits claimant to QE Dr. Villalobos agreed with the FCE dated 7/3/13, placing claimant Qa 5. MAXIMUM_MEDICAL IMPROVEMENT, IMPAIRMENT RATING AND WORK RESTRICTIONS - Dr. Johns put claimant Si and return of claimant to previous employment. Dr. Jarolem placed claimant QS with a Dr. Allende placed claimant at Dr. Villalobos placed claimant at r. Allende said claimant can Qa and Dr. Villalobos concurs with the FCE placing claimant (qa 6. ESTIMATE OF COST OF FUTURE MEDICAL CARE - Dr. Villalobos stated on 7/26/12 that claimant should continue on (ig and Gaus. As of 9/9/13, Dr. Villalobos prescribed (iE and continued (Qiu This information was taken into consideration in arriving at a reasonable lump sum payment for the release from liability for future medical benefits. 7. AGE, EDUCATIONAL BACKGROUND AND WORK HISTORY - The claimant is 56 years of age (DOB: 6/15/57) and has a college education. He is able to read, write and do simple math. His work history includes employment as a medical examiner's assistant. At the time of the alleged injury, the claimant was working as a Special Assistant Forensic Investigator. 8. TT T NT DI RG M ATY F TUR MP TI - Subject to the approval of the judge pursuant to Florida Statutes §440.20(11}(c},(d) & (¢), employer/carrier/servicing agent will pay to the claimant $330,900.00 in accordance with the statutory formula, in full satisfaction of the obligation or liability to pay all past and future benefits of whatever kind or classification available under the Florida Workers’ Compensation Law including, but not limited to, future medical benefits, monetary compensation as contemplated under Section 440.15, Florida Statutes, impairment benefits, death benefits, attorney's fees, past medical benefits and rehabilitation and training and education benefits including temporary total disability compensation under Section 440.49(1989)&(1990) and 440.491(6)(b) (1993), Florida Statutes, on account of the alleged accident or occupational disease referenced herein which shall be allocated as follows: a. Past and future compensation Benefits $ b. Past medical expenses $ C. Future medical expenses $265,250.00 1. MSA for Medicare expense of $355,201.00 funded by annuity cost of $173,170.00 2. Up-front cash of $66,494.00 3. Non-Medicare covered medical costs of $25,586.00 d. Rehabilitation temporary total disability compensation and rehabilitation and training and education expenses $ 25,000.00 e. Attorney's fees and costs $40,650.00 TOTAL: $330,900.00 *It is not the intention of the Workers’ Compensation Carrier to shift responsibility of future medical benefits to the Federal Government. The sum of $ for future Medicare- covered expenses is intended directly for payment of these expenses. Upon proof that Medicare 2 covered expenses exceed $ those expenses will be forwarded to Medicare for payment of covered expenses with proper documentation. It is the responsibility of the claimant/ beneficiary to submit documentation of paid bills related to the work-related injury or illness totaling the amount of $ before Medicare will make payment on any covered expenses related to the work injury or illness. Consideration has been given to the fact that the claimant is currently receiving Social Security Disability benefits. This allocation is based on the workers’ compensation fee schedule. The injured worker should be advised that all payments to providers are to be adjusted accordingly, and any monies paid in excess of the fee schedule will not count toward the allocation. The Medicare set-aside funds in this case are to be self-administered by the claimant. Claimant has been provided with the directives issued by CMS regarding his rights and responsibilities in this regard as set forth in Exhibit “A” “Terms and Conditions for Beneficiary Administered Set Aside Account” attached hereto and incorporated by reference herein. Claimant understands that the MSA funds must not be used to pay the claimant's expenses. Claimant understands that the MSA funds must be placed in an interest-bearing account, and this account must be separate from the individual’s personal savings and checking accounts. The funds in this account may only be used for payment of medical services related to the work injury that would normally be paid by Medicare. If payments from this account are used to pay for services that are not covered by Medicare, Medicare will not pay injury-related claims until these funds are restored to the MSA account, and then properly exhausted. Claimant further understands that annual reporting must be prepared for submission to Medicare to include summaries of the transactions and status of the account. These summaries are to include the date of each service, procedure performed, diagnosis and paid receipt or canceled check. In the event the claimant is a Medicare beneficiary, there may be an outstanding Medicare lien at the time of the settlement in this case. If the Medicare lien remains outstanding at the time this case is settled, the lien will be satisfied by the claimant as part of the terms of the settlement. This settlement will not become final until the amount of the Medicare lien has been determined and the lien is satisfactorily resolved with Medicare by the claimant, The parties agree that the injured claimant has attained maximum medical improvement. In addition, the payment of the lump-sum set forth herein will definitely aid in the rehabilitation of the injured claimant or will otherwise be in his best interest. Upon receipt of the lump-sum, the employer/carrier/servicing agent will be forever released and discharged from the obligation or liability to pay any and all benefits of whatever kind or classification payable under the Florida Workers' Compensation Law. The claimant does hereby waive any right he may have to any and all penalties and/or interest on account of the accident or occupational disease referenced herein and specifically agrees that the employer/carrier/servicing agent will have thirty (30) days from the date of the entry of the Order approving the Motion for Approval of Attorney's Fee and Allocation of Child Support Arrearage to make payment. As further consideration for the aforementioned payment, the claimant agrees and does hereby release, discharge, and surrender any and all claims, whether or not asserted against the employer/ carrier/servicing agent, or any of its officers, agents, servants, employees, directors, successors, assigns, and any other person or entity so connected to the employer/ carrier/servicing agent, of any nature whatsoever, without any limitations thereof under Chapter 440. 9. TORNEY‘ P BY NT AND W;, - The claimant has been represented by Edward H. Hurt, Jr, Esquire, in connection with this matter who is entitled to a fee for legal services rendered. $40,000.00 is a reasonable fee for such services, and is within the guidelines for the determination of a reasonable fee as set forth in F.S. §440.34(1). In addition thereto, the claimant shall also reimburse the attorney $650.00 for non-taxable costs. Notwithstanding the provisions of F.S. §440.34(3)(a-d), the claimant and not the employer/carrier/servicing agent is responsible for the payment of his own attorney's fees because this settlement was made under FS. §440.20(11)(c), (d), & (e) F. S. (2001). The claimant has been informed of the right to a hearing on the amount of the fee charged by the attorney and hereby waives his right to such a hearing. The fee and non-taxable costs shall be paid from the settlement proceeds, thereby making the net settlement amount $290,250.00. The claimant guarantees to hold the employer/carrier/servicing agent harmless from any claim or lien for attorney's fees and costs by any attorney with respect to any date of accident listed in this settlement agreement. The parties further stipulate and agree that the claimant is responsible for said claims or liens of prior attorneys. 10. WAIVER OF RIGHT TO HAVE CASE HEARD BY JUDGE OF COMPENSATION CLAIMS RIGHT TO TIO R FI N - The claimant understands that he does hereby relinquish the right to have any unresolved conflicts or disputes involving the right to monetary compensation benefits, impairment benefits, death benefits, attorney's fees, past due medical benefits, future medical benefits and rehabilitation and training and education benefits heard and decided by a judge. 11. PRESENT WORTH AND POSSIBLE OFFSET FOR SOCIAL SECURITY DISABILITY BENEFITS CONSIDERED - In reaching this agreement, the parties have considered the present value of all future payment of indemnity benefits, impairment benefits, medical benefits and death benefits potentially payable to the claimant under the Florida Workers’ Compensation Law on account of the injuries referenced herein. The injured claimant was born 6/15/57 and his life expectancy is approximately 24 years, or 1,248 weeks. When the present value of the lump sum payment for future indemnity benefits of $25,000.00 herein is prorated on a weekly basis over the claimant's life expectancy, the lump sum is equal to payment of future indemnity benefits at a rate of $20.05 per week. This periodic repayment schedule results in a substantial loss to the claimant on a consistent basis. Taking that into consideration, the parties hereby agree that those weekly payments of indemnity benefits are the same as if the lump sum would have been paid to